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Surgical issues top list of ophthalmology medico-legal complaints

A snapshot of medico-legal matters against ophthalmologists insured by an Australian medical defence organisation has found claims for compensation and regulatory complaints most commonly relate to surgical issues involving cataracts, corneal operations and oculoplastic procedures.

The new ophthalmology-specific data collated by doctor-owned Avant, which provides medical indemnity insurance and medico-legal advice, also shows that one in nine ophthalmologists had a matter raised about their care in FY2018-19.

Over a five-year period between July 2014 to June 2019, regulatory complaints (57%) and compensation claims (26%) were the most common legal matters received by the firm, demonstrating that ophthalmologists are more likely to be subject to a complaint than be sued.

Employment disputes accounted for 7% of matters, while 4% related to Medicare and 7% were classified as ‘other’.

Melissa Yee.

The organisation also conducted a retrospective review of routinely collected and coded data based on more than 120 matters involving its ophthalmologist members from across Australia. These were compensation claims and regulatory complaints indemnified and closed from July 2014 to June 2019.

Within ophthalmology claims and complaints, the most common type of issue was procedural or surgical. A further breakdown of these cases showed 64% occurred at the intra-operative stage – such as allegations of poor surgical performance/skill/ competence – while 20% occurred at the pre-operative phase for issues like incorrect intraocular lens selection. The remaining 16% were post-operative issues.

Further, the most common types of procedures involving surgical allegations were; extraction and insertion of a lens; keratoplasty and other procedures on the cornea; and plastic procedures on soft tissue such as eyelids to treat blepharochalasis or ptosis.

Ms Melissa Yee, research and evaluation manager at Avant, and Ms Eunice Ku, claims coding analytics manager, compiled and interpreted the data.

They said it was not surprising procedural/surgical issues were the main type of allegation, given the nature of ophthalmologists’ work.

Eunice Ku.

“This is not dissimilar to other surgical specialties such as orthopaedic surgeons, general surgeons, and obstetricians and gynaecologists. Generally, we have found trends in medico-legal matters have some correspondence with the types of work involved,” Yee and Ku stated.

The review also identified other issues that can give rise to claims and complaints, such as communication with patients, billing, diagnosis and consent issues.

“In our experience, often when there are allegations of procedural or surgical issues, there can actually be shortcomings in the patient relationship/communication and/or the consent process. If a patient does not understand the treatment limitations, or the potential post-operative issues, it is not uncommon for them to be unhappy with the outcome and complain that the surgery was performed poorly,” Yee and Ku said.

An evaluation of expected standards found that, overall, doctors met the standard in 73% of cases, while 27% did not. However, it was noted that experiencing a medico-legal matter is often stressful, even if the care is appropriate, and can take years to resolve in some cases.

“Through our data, we can better understand the features, characteristics, or deficiencies in care that give rise to claims and complaints. By highlighting the common areas of risk which led to claims or complaints against ophthalmologists, we hope doctors are able to reflect on their own practice and take steps to reduce their medico-legal risks,” Yee and Ku added.

In other findings, the majority of diagnosis complaints were during the initial assessment stage, and included allegations of a missed or delayed diagnosis due to inadequate examination.

Managing expectations 

Recently, the Australian Society of Ophthalmologists joined other peak medical bodies in support of the new Informed Financial Consent: A Collaboration Between Doctors and Patients guide that aims to create greater medical fee transparency and prevent ‘bill shock’ for patients.

Peter Sumich.

The organisation’s vice president and Sydney cataract and refractive surgeon Dr Peter Sumich said patients’ expectations can also give rise to complaints.

He said patients talk to friends who were spectacle independent after cataract surgery, but they don’t always realise every case has unpredictable individual variations and not all have the same visual requirements.

“I have occasionally had problems with standard cataract patients who become very hostile when faced with the need for glasses,” he said.

“And even more so with extra costs for enhancement with LASIK or supplementary piggyback lenses even when they were consented for prior. A recent patient mixed up the terms ‘supplementary’ and ‘complimentary’, which was interesting. In their minds their cataract procedure had become a refractive surgery. Whether it is a memory, language or a personality issue is irrelevant once the patient is in the chair going ‘full steam ahead’.”

He has adopted the mantra that five minutes’ extra chair time preparation can be worth an hour post-operation.

“We conduct staff discussions on any patient who has complained; in order to put procedures in place for future problems. My staff have been trained to listen to the voice in their head if they think a patient may have an expectation mismatch,” Sumich said.

RANZCO immediate past-president Associate Professor Heather Mack said complaints against doctors is a serious issue and understanding patterns is necessary to improve practice.

“RANZCO notes that the number of reported events would appear to be small for ophthalmology. RANZCO will continue to work with Fellows to improve outcomes and standards, including working
with indemnity companies to explore complaints and events data,” she said.

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